ICD-10 Q&A
Disclaimer: All of the ICD-10 codes within this document were chosen by PTSF registry staff and reflect our opinion of the best code using standard ICD-10-CM/PCS guidelines and coding norms. As all good coders and trauma registrars do, you are more than welcome to disagree with any of the information contained in this document.
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(2/4/2016)
Q. What is the best ICD-10 code for open reduction and internal fixation of right bimalleolar ankle fracture?
Answer: In this situation both 0QSJ04Z and 0QSG04Z should be coded.
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(2/2/2016)
Q. What is the correct ICD-10 code for a patient smoking while on oxygen that sustains burns to the skin from a flash? Would we use W40.1 (explosion of explosive gas) or X04 (ignition of highly flammable material)?
Answer: X04.XXXA is the appropriate ICD-10 code in this situation.
Q. Would a box truck (ie delivery truck or moving truck that people rent) be considered a transport vehicle (o)?
Answer: Yes, a box truck would fall under transport vehicle (o). Please refer to the beginning of category V00-V99 in your ICD-10 coding book for definitions of transport vehicles.
Q. How should a CT scan done on a patient at an outside facility that we cannot get information on the type of contrast or if contrast was used be coded?
Answer: The PTSF recommends that you code Z, none when information regarding contrast is unknown.
Q. How would you code an escharotomy in a burn patient on multiple sites?
Answer: An excisional escharotomy or excisional debridement of the skin should be coded to table 0HB. Assuming the escharotomy in this example is excisional, it should be coded to 0HB_ _ZZ. Multiple codes may have to be recorded to capture multiple body parts.
Q. How would the following scenario be coded?
The neck laceration was inspected. We verified that the platysma had not been violated. We then inspected to borders of the laceration which we found to be irregular. The edges were trimmed with tenotomy scissors to provide better approximation. The superficial fascia was then reapproximated with simple interrupted 3-0 vicryl sutures. The skin was closed with 4-0 nylon sutures in a vertical mattress fashion. The incision was dressed with bacitracin, xeroform, a 4x4, and a tegaderm. Drapes were then removed and the wrists prepped and draped.
Answer: Based on the information provided, the PTSF recommends coding 0JQ_0ZZ. The ICD-10 code for inspection should not be included. The root operation inspection represents procedures where the sole objective is to examine a body part. Inspection is not coded separately for procedures that are continued with any other root operation being performed. Also according to guideline B3.11a, inspection of a body part(s) performed in order to achieve the objective of a procedure is not coded separately.
Q. Do we always try to code to a body part if possible vs a region?
Answer: A specific body part should be coded instead of an anatomical region if documented. However, typically in trauma not one specific body part is examined. An entire anatomical region will be examined to diagnose an injury. For example, the entire arm will be x-rayed, not just the humerus. This question has also been submitted to Coding Clinic for further explanation.
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(1/28/2016)
Q. What is the best ICD-10 code for injured hand in snow blower?
Answer: The best ICD-10 code in this situation is W29.3XXA.
Q. If a patient falls out of bed and strikes an object such as a table, should we be coding both the fall from bed and striking an object?
Answer: At this time there is no single code in ICD-10 for a fall from other level and striking an object. In this situation code W06.XXA for the fall from bed and then W22.09 to capture striking against other stationary object. Since you have two codes to record, code the mechanism which resulted in the most severe injury first.
Q. Is V48.5XXA the correct ICD-10 code for a vehicle that ran off the road into a ditch?
Answer: Yes, V48.5XXA is the correct code for a car driver that is injured due to driving off the road into a ditch.
Q. Is X08.8 the appropriate code for a burning by an exploding e-cigarette?
Answer: The PTSF recommends coding W40.9 in this situation. W40.9 is the ICD-10 code for explosion NOS and should be used since “exploding” is used within the documentation. X08.8 is the appropriate code for a burn to the face. If the e-cigarette caught on fire and burned the patient, this code could be appropriate. However, in this situation it appears the e-cigarette physically exploded.
Q. Is there a specific ICD-10 code for ECHO? Should separate codes be used for heart, arteries, and pericardium?
Answer: ECHO ICD-10 codes can be found in table B24. If the entire heart is being examined, code B246_Z_. Select the appropriate 5th and 7th characters based on your documentation. You would also not have to code the coronary arteries or pericardium separately.
Q. The PTSF has recommended that BW0_ZZZ be used for plain film x-rays. What is difference between BW0 and BN0, BP0, or BQ0 codes for plain radiography?
Answer: Table BW0 is plain radiography of anatomical regions. Tables BN0, BP0 and BQ0 are tables containing codes for plain radiography of specific body parts. Typically, in trauma care an entire anatomical region will be x-rayed to determine the appropriate diagnosis. For example, the entire lower extremity will be x-rayed, not specifically the femur. If you have the appropriate detail in your documentation that a specific body part is the only focus of the plain radiography, you are able to use the codes for specific body parts.
Q. What is the correct ICD-10 code for a bar/tavern?
Answer: The correct ICD-10 code for a bar/tavern is Y92.511.
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(1/21/2016)
Q. What is the correct ICD-10 code for a hip arthroplasty with a Zimmer 10mm extended -offset, proximal coated Press-fit; a 28 mm inner liner; a 48-mm liner; negative -3 femoral head?
Answer: Based on the information provided, we recommend navigating to table 0SR and determining the correct body part, device and qualifier based on your documentation.
Q. What is the correct ICD-10 code for a Spica cast and a Pavlik Harness?
Answer: The correct ICD-10 code for a Spica Cast and a Pavlik Harness is 2W3_X_Z. Select the appropriate body part and device based on your documentation. The 6th character (Device) should be recorded as 2, cast for the Spica Cast and Y, Other Device for the Pavlik Harness.
Q. What is the correct ICD-10 code for CT of the thorax without contrast?
Answer: The correct ICD-10 code for CT of the thorax without contrast is BW24ZZZ. We recommend that BP2W_ZZ not be used. This table is used for CT’s in which a specific bone or bones are being looked at. A CT of the thorax in trauma is typically looking at a certain anatomical region in general.
Q. What is the correct ICD-10 code for chest needle decompression?
Answer: Needle decompression of the chest should be coded to OW9B3ZZ. In the alphabetic index both “thoracentesis” and “thoracotomy” will direct you to table OW9. Within the alphabetic index, “throacostomy” will direct you to table 0B9. This table should only be used when a drainage device is used.
Q. Does ICD-10 separate CT vs CTA?
Answer: When coding in ICD-10 it appears that code BW291ZZ should be used for both CT and CTA of the head and neck. ICD-10 does not seem to have a separate code for CTA or “other tomography.” PTSF staff is verifying this response with coding clinic. Once a response is received, it will be posted here.
When coding in ICD-9 the PTSF instructed PA trauma centers to utilize 87.04 for CTA of the head and/or neck. A separate code of 87.03 was utilized for CT of the head. Please note that code 87.04 is used for “other tomography,” not just CTAs in ICD-9. Therefore, ICD-9 did not have a specific code for CTAs either.
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(1/19/2016)
Q. We used to utilize ICD-9 code 88.39 to record all x-rays taken at a referring facility. Do we now have to code every x-ray that was performed at a referring facility?
Answer: Each ICD-10 anatomical region x-rayed at the referring facility should be coded to BW0_ZZZ using the appropriate 4th character.
Q. What is the correct ICD-10 code for CT scan of the facial bones?
Answer: The correct ICD-10 code for CT scan of the facial bones is BN25_ZZ using the appropriate 5th character.
Q. When coding head and neck CT’s, should we be coding head and neck (combination code) or head and C-spine (two separate codes)?
Answer: If the CT encompasses the entire anatomic region, which in trauma it typically does, we recommend using a combination code. Therefore, BW29_ _Z would be appropriate.
Q. What is the correct ICD-10 code for a PICC line insertion?
Answer: The insertion of a PICC line is not required to be captured by the PTSF. If recording the insertion, we recommend using the 05H, 06H or 0JH tables.
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(1/14/2016)
Q. What is the correct ICD-10 code for an exploratory laparotomy for inspection of upper, lower, and mesentery?
Answer: The correct ICD-10 code in this situation is 0WJG_ZZ.
Q. What is the correct ICD-10 code for an accident NOS or a specified injury NEC?
Answer: The correct ICD-10 code for Accident NOS or specified injury NEC is X58.XXXA.
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(1/12/2016)
Q. Should the T code for child abuse (T74.12XA) be recorded in the Primary ICD-10 Mechanism field? If not, which code should be used for child abuse?
Answer: For cases of confirmed abuse or neglect an external cause code from the assault section (X92-Y08) should be recorded in the Primary ICD-10 Mechanism field to identify the cause of any physical injuries. The appropriate “T” code, T74 for confirmed abuse or T76 for suspected abuse, should be recorded in the Secondary ICD-10 Mechanism field. This question will be discussed further at the Trauma Registry Committee in February 2016.
Q. What is the difference between an assault code and an abuse code?
Answer: In order to code abuse it must be documented as suspected or confirmed within the medical record. If you are unsure whether or not to code abuse or assault, look for specific documentation of abuse within the medical record, multiple visits, or old contusions or abrasions that may alert you to suspect abuse as opposed to assault. Query the physician if you are suspicious of abuse but do not see documentation of confirmed or suspected abuse within the medical record.
Q. ICD-10 code BW251ZZ includes CT of the chest, abdomen and pelvis. In ICD-9 these were coded separately. Should these be coded separately in ICD-10 as well?
Answer: PTSF staff recommends that the combination code BW25_ _Z be used to code CT of the chest, abdomen and pelvis. They should not be coded separately. This question will be discussed further at the Trauma Registry Committee meeting in February 2016.
Q. Is there an ICD-10 code for CT of the chest?
Answer: Per convention A10, “and,” when used in a code description, means “and/or.” Therefore, the correct ICD-10 code for CT of the chest is BW24_ _Z. You must select the correct contrast (character 5) and qualifier (character 6) based on your documentation.
Q. Should the ICD-10 code for CT of the thorax be used in addition to the ICD-10 code for CT of the chest, abdomen and pelvis when thorax is stated within the dictation?
Answer: PTSF staff recommends that you do not include an additional code for CT of the thorax in this situation. Code only BW25_ _Z for the CT of the chest, abdomen and pelvis.
Q. What is the correct code for an orogastric tube placed on an intubated patient for drainage?
Answer: The correct ICD-10 code in this situation is OD9_ _ _ _. The body part, approach, device and qualifier must be determined based on your documentation.
Q. What is the correct ICD-10 code for a fall from a hover board?
Answer: The correct ICD-10 code in this situation is V00.181A.
Q. What is the correct ICD-10 code for internal cardiac massage?
Answer: The correct ICD-10 code in this situation is 02QA0ZZ. The root operation repair involves restoring the body part to its normal function.
Q. What is the correct ICD-10 code for a CTA of upper extremity (L) brachial artery?
Answer: This question was taken to Coding Clinic on 1/12/2016. Once a response is received, the answer will be posted here.
Q. What is the correct ICD-10 code for placement of an IVC filter with direct ultrasound guidance, percutaneous, with infusion device?
Answer: The correct ICD-10 code in this situation is 06H03DZ. An additional code for ultrasound guidance is not needed.
Q. For ICD-10 code B54DZZ_, what does the 7th character qualifier “Intravascular” mean?
Answer: Intravascular ultrasound (IVUS) is a medical imaging methodology using a specially designed catheter with a miniaturized ultrasound probe attached to the distal end of the catheter. The proximal end of the catheter is attached to computerized ultrasound equipment. If this technique was used, record 3, intravascular as the 7th character qualifier.
Q. Should we be coding all CT scans in ICD-10 now that there are specific codes for other body parts/regions?
Answer: PTSF staff recommends that you code all CT scans using the specific appropriate code(s) in ICD-10. This question will be discussed further at the Trauma Registry Committee meeting in February 2016.